ABC | Volume 115, Nº1, July 2020

Review Article Costa et al. Cardiovascular Imaging and Interventional Procedures Arq Bras Cardiol. 2020; 115(1):111-126 or confirmed COVID-19; b) guiding physicians to safely perform the tests and procedures, preventing environmental and healthcare personnel contamination. 2. Approach to patients with suspected or confirmed COVID-19 The approach to patients with suspected or confirmed COVID-19 should begin with the proper characterization of their signs and symptoms. Those with mild symptoms, such as cough, fever, and sore throat, can be followed up in low- complexity units or at their homes. Those with more severe symptoms (oxygen saturation <94% in room air, respiratory distress, tachypnea, hypotension, acute respiratory failure) should be referred to specialized centers. On the initial contact, symptomatic individuals should be given a surgical mask and directed to a specific room aimed at respiratory isolation; in addition, they should receive instructions on hand hygiene to prevent contamination of the environment and other individuals. 4 The identification of at-risk patients should comprise the assessment of clinical comorbidities known to be associated with a more severe course of the disease. 7,13 Patients with arterial hypertension (AH), chronic cardiovascular disease, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), or chronic kidney disease, in addition to immune suppressed or elderly patients, are more susceptible to develop complications, being considered a risk group. 4 Patients with severe symptoms and/or of the risk group are prone to develop COVID-19-related cardiovascular complications. 8,9 Zhou et al., 9 in a cohort with 191 patients, have reported high prevalence of AH (30%), DM (19%), coronary arterial disease (CAD - 8%), and COPD (3%). 9 Of the 54 deceased patients (28%), 67% had a comorbidity, AH being identified in 48%, DM in 31%, and CAD in 24%. Advanced age was an independent predictor of mortality.9 Other important markers of severity in those patients are high serum levels of troponin, NT-proBNP, and D-dimer. Those with troponin elevation had more severe forms of COVID-19, with a higher incidence of acute respiratory distress syndrome (ARDS) and death. 11 High troponin levels are accompanied by an elevation in markers of inflammation, thrombosis and cardiac dysfunction, patients with those characteristics being more likely to develop acute heart failure and shock. 8,9,11 On admission, patients with clinical or laboratory findings suggestive of more severe disease should have their cardiovascular function evaluated via clinical assessment, measurement of biomarkers, and imaging tests. 12,14 The most often performed imaging tests and interventional procedures are described in the following sections. 3. Echocardiography Echocardiography has a well-established role in the diagnosis, prognostic assessment, and therapeutic guidance of several cardiovascular diseases. However, because it requires a close contact between examiner and patient, it poses a high risk of contamination. The pandemic has called for the urgent reorganization of echocardiography laboratories to minimize the exposure to COVID-19 and ensure the protection of patients and healthcare personnel. 5 In light of this, the Brazilian Society of Cardiology Cardiovascular Imaging Department has issued a document to aid healthcare professionals during this pandemic. 5 Echocardiography should not be performed routinely during the pandemic, especially in patients with confirmed COVID-19. However, echocardiography professionals will continue to be exposed in certain clinical scenarios in which that exam can play a decisive role in the differential diagnosis and clinical management of more severely ill patients. COVID-19 is known to cause severe cardiovascular manifestations; in addition, previous cardiovascular disease is common in patients with COVID-19, being associated with worse prognosis. 9,14,15 3.1. General Precautions The provision of patient care amidst the pandemic should meet the following safety recommendations to minimize the risks of healthcare personnel and patient exposure to COVID-19: (a) to define whether the test is deemed essential on the occasion; (b) to assess in advance the risk of contamination; (c) to respect the general hand hygiene and contact restriction rules; and (d) to observe the rational and strict use of proper personal protective equipment (PPE) according to the test type and contamination risk. 5 When the likelihood of COVID-19 is low (low-risk areas and negative SARS-CoV-2 test), TTE in an asymptomatic patient requires the echocardiographer to perform thorough hand hygiene and wear gloves and surgical mask, and the patient to wear surgical mask as well, during the test. When the risk is moderate to high (symptomatic patients with suspected or confirmed COVID-19), the safety measures include hand hygiene and use of gloves, surgical mask (or N95 mask, when available), gown, hair covers and eye protection (goggles or face shield) by the examiner. The patient must wear a surgical mask. When transesophageal echocardiography (TEE), an aerosol-generating procedure, is necessary, the N95 mask or similar must be added to the aforementioned PPE, for respiratory protection. In addition, shoe covers, as well as a protective cover for the transducer, are recommended. For patients with suspected or confirmed COVID-19 on non-invasive or invasive mechanical ventilation, respiratory protection should also be adopted when performing a TEE. 16 For inpatients, bedside echocardiography should be preferred, taking proper protective measures and reducing the number of individuals in the room to the lowest possible. The devices and transducers should be thoroughly cleaned and disinfected right after use according to the manufacturer’s specifications. Echocardiography laboratory staff with the following characteristics should be kept away: aged over 60 years, immunosuppressed, pregnant, and with chronic diseases. 5,17 3.2. Indications for Echocardiography in Patients at Low Risk of COVID-19 During the pandemic, the indication for echocardiography in patients at low risk of COVID-19 should be based on the proper use of the exam; in addition, the exam should only be performed if the resulting information is deemed essential for 112